A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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Correct Answer is B

Explanation

A. "Take an extra dose of insulin lispro prior to aerobic exercise." This is incorrect. Exercise can increase insulin sensitivity, meaning the client may need to reduce the dose of short-acting insulin (such as insulin lispro) before exercise to avoid hypoglycemia. The nurse should not recommend taking an "extra" dose of insulin prior to exercise.

B. "Draw up the insulin lispro and insulin glargine in separate syringes." This is correct. Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should never be mixed in the same syringe. Insulin glargine is acidic, and mixing it with other insulins can alter its action and effectiveness.

C. "Expect insulin glargine to be cloudy." This is incorrect. Insulin glargine should be clear and colorless. If insulin glargine appears cloudy, it may indicate that the insulin is expired or has been improperly stored.

D. "Anticipate that the insulin glargine will peak in 3 hours." This is incorrect. Insulin glargine has no pronounced peak. It provides a steady release of insulin over 24 hours and is designed to be taken once daily.

A. Laissez-faire leadership style B. Rigid expectations of behavior C. Self-blame for financial problems D. High self-esteem

Correct Answer is B

Explanation

A. Laissez-faire leadership style: A laissez-faire leadership style generally involves being permissive or non-directive, which is not typically associated with perpetrators of child abuse. Instead, abusive caregivers often have controlling or rigid parenting styles.

B. Rigid expectations of behavior: This is characteristic of many perpetrators of child abuse. They may have unrealistic or excessively strict expectations for their children's behavior, which can lead to frustration, anger, and, ultimately, abusive behaviors when those expectations are not met.

C. Self-blame for financial problems: While perpetrators of child abuse may experience stress due to financial issues, self-blame is not a defining characteristic. The stress from financial problems can contribute to abusive behaviors, but it is not the key factor.

D. High self-esteem: Perpetrators of child abuse typically have low self-esteem and may feel inadequate as parents. High self-esteem is not generally a characteristic of individuals who abuse children. Instead, feelings of powerlessness or frustration often contribute to abusive behavior.

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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